All interventions need to be individualized and reflect the
goals of an informed patient. Patients who enroll in the hospice program 'early' may still
be receiving active chemotherapy. There are many palliative chemotherapy regimens or
hormal therapies that may improve the quality of life of incurable patients and would not
be inappropriate within hospice. Often a trial of steroids (e.g. Decadron) may benefit
many patients.
Other considerations:

Palliative chemotherapy for non-small cell lung cancer.

Adelstein DJ. Semin Oncol 1995 Apr;22(2 Suppl 3):35-9

The results of several randomized trials suggest a marginal survival
benefit for patients with metastatic non-small cell lung cancer after treatment with
chemotherapy. Toxicity, cost, and inconvenience have led many physicians to question
whether chemotherapy has even a palliative role in this disease. Furthermore, it is well
established that patients with a poor performance status, who are most in need of
symptomatic palliation, are also those who are least likely to benefit and most likely to
experience treatment-related toxicity. Nonetheless, evidence of a symptomatic benefit from
combination chemotherapy has been presented. Indeed, symptomatic palliation can result
even in the absence of a conventionally defined chemotherapy-induced response.

Quality of life during chemotherapy in non-small cell lung cancer patients.

Fernandez C. Acta Oncol 1989;28(1):29-33

After chemotherapy 17 of 19 patients (89%) gained weight; 20 presented
anorexia, 10 of those (50%) improved; 15 had pain, 7 of those (47%) were alleviated; cough
was reported in 22, in 10 (45%) it was ameliorated; hemoptysis disappeared in 10 of 11
patients (91%); of the 9 patients who had dyspnea, 7 improved (78%); and astenia was
attenuated in 8 of 16 patients (50%). Quality of life was reported improved in 75% of
those patients who had considered themselves seriously affected prior to the treatment

Ganz PA. Cancer 1989 Apr 1;63(7):1271-8

Current chemotherapy treatment of metastatic non-small cell lung cancer has
demonstrated some objective responses, but is still largely palliative. This report
reviews the results of a randomized trial in patients with advanced metastatic non-small
cell lung cancer which compared treatment with supportive care (treatment with palliative
radiation, psychosocial support, analgesics, nutritional support) to supportive care plus
combination chemotherapy with cisplatin and vinblastine. Although the patients receiving
combination chemotherapy had a slightly longer median survival (20.43 weeks versus 13.57
weeks), it was not statistically significant (P = 0.09). In addition, the patients
receiving chemotherapy experienced serious toxicity, and showed no significant benefit in
terms of quality of life as measured by Karnofsky performance status score.

Clinical benefit from palliative chemotherapy in non-small-cell lung cancer extends to
the elderly and those with poor prognostic factors.

Hickish T. Br J Cancer 1998 Jul;78(1):28-33

When the independent factors for symptom response were used to group patients into
prognostic categories, 30-48% of patients with an adverse set of factors had symptom
relief. Similarly using the relative risk of death to subgroup the patient population, 54%
of patients at high risk of death (greater than 8.0), with a median survival of 2.5
months, had symptom relief. Additionally, older age is positively associated with
objective response and the majority of patients with the worst prognosis have symptom
relief from treatment with chemotherapy.

Patient preferences for treatment of metastatic breast cancer: a study of women with
early-stage breast cancer.

McQuellon R. J Clin Oncol 1995 Apr;13(4):858-68

The greater the toxicity potential of the treatment, the less likely patients were to
accept the treatment, although approximately 15% of patients would prefer high-risk
treatment for as little as 1 month of added life expectancy. Between 34% and 82% of
patients would prefer different therapies for a 6-month addition to life expectancy,
whereas almost all patients would accept treatment for a 5-year increase in length of
survival. Moreover, 76% of patients would prefer standard treatment or an experimental
agent to reduce symptoms or pain, even if such treatment did not prolong life.

Measuring health-related quality of life in clinical trials that evaluate the role of
chemotherapy in cancer treatment.

Michael M. CMAJ 1998 Jun 30;158(13):1727-34

Quality of life is a subjective multidimentional concept that can be assessed by means
of validated questionnaires completed by patients. Palliation implies improvement in
either the duration or quality of life remaining. A few large trials incorporating
these principles have shown that chemotherapy can provide palliation for patients with
advanced cancer.

Silvestri G. BMJ 1998 Sep 19;317(7161):771-5

The minimum survival threshold for accepting the toxicity of chemotherapy varied widely
in patients. Several patients would accept chemotherapy for a survival benefit of 1 week,
while others would not choose chemotherapy even for a survival benefit of 24 months. The
median survival threshold for accepting chemotherapy was 4.5 months for mild toxicity and
9 months for severe toxicity. When given the choice between supportive care and
chemotherapy only 18 (22%) patients chose chemotherapy for a survival benefit of 3 months;
55 (68%) patients chose chemotherapy if it substantially reduced symptoms without
prolonging life.

Thatcher N. Semin Oncol 1997 Jun;24(3 Suppl 8):S8-6-S8-12

Recent studies have indicated that chemotherapy not only provides some survival
benefit, but also reduces tumor-related symptoms and improves the performance status of
patients receiving chemotherapy. Data from single-agent gemcitabine studies demonstrate
improvements in a range of tumor symptoms, including cough, hemoptysis, pain, dyspnea, and
anorexia, as well as increases in performance status. Indeed, more patients benefit from
gemcitabine chemotherapy than suggested by the objective response rate.